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What could be the diagnosis?
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What could be the diagnosis?

I have had Type 1.5 Diabetes for 27 years on an Insulin Pump. I have several comps including anemia, chf (dyastolic), cad, ckd and severe neuropathy.  I also have GERD and a history of colon polyps. I have a colonoscopy about every 3 years and a gastroscopy every 2 years.  2 years ago I went to a Hematologist at the Beth Israel Deaconess Medical Center in Boston.  After routine blood work he told me that my ferritin level was 18 and that I was bleeding somewhere.  He advised me to go to my Gastroenterologist.   At that time, as I had recently had a Gastroscopy and Colonoscopy, the Gastroenterologist suggested a camera swallow.  That was negative. My pcp treated me with Iron and at her lab, I feel not a very good lab, my Ferrtin was normal.  A few days ago I returned to the Hematologist becuase I have had frequent spontaneous bloody noses.  He again repeated blood work.  MyHgb was 12 and my Hct was 34.6. My rbc was 4.06.  My ferritin was very low at 15 this time.  There range is 30-400. My regular iron was 64  range of 45-160. My calTIBC 391 260-470 range. My TRF was 301 200-360 range. He said that I am either bleeding somewhere or that I am not absorbing Iron. Through his observation, as I am pretty hefty, he said I looked like I was absorbing well.  He suggested that I call my PCP  and/or my Gastroenterologist and have a Colonsocopy and also be tested for Celliac.  A while back I was tested for Celliac and it was normal at that time.  I called my PCP and she insulted me and said I was playing Doctors like it was some kind of sport. One other FYI for about 2-3 months between December and February, I was having major episodes of Syncopee and the diagnosis leaned toward vasal vagal and autonomic dysfunction.  I have had a confirmed diagnosis of both Autonomic and Cardiac Autonomic Neuropathy for about 4-5 years now.  My question is what could be causing this low Ferritin and should I be concerned about it?  I must admit I am a bit anxious and concerned.
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Indeed, a low ferritin can be indicative of iron deficiency anemia.  And the most common cause of this would be a GI bleed.

That said, you had a comprehensive workup, including the endoscopies and the camera endoscopy.

Sometimes, bleeds in the small bowel can be difficult to detect, and more specialized tests like a bleeding scan or push enteroscopy should be considered.  

Serially monitoring the CBC can be done to ensure the hemoglobin level stays stable, and I agree with the iron supplementation.

Discussing these tests with another gastroenterology opinion should be considered, and you may also want to consider a second hematology opinion.

I would also evaluate the thyroid, as low levels here can also reduce the ferritin level.

If the diagnosis continues to be non-revealing, then simply serial blood tests to ensure stability of the values can be considered.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Kevin Pho, M.D.
www.kevinmd.com
www.twitter.com/kevinmd
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